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READER QUESTIONS: Multiply for Correct Graft Code

Question: We have a trauma victim who requires a skin graft. The donor site is the right thigh, and the recipient site is the abdomen. The operative note describes the graft as a 鈥渟plit thickness skin graft, size 25 x 18 cm.鈥� Should I report 15000?


Michigan Subscriber 
 

Answer: Your code choice for split thickness grafts depends on the amount of square centimeters involved. In this case, you would multiply 25 times 18 to determine the full area--which equals 450 square cm.

For the graft harvesting--assuming, of course, that you have the appropriate documentation--you would report 15000 (Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar [including subcutaneous tissues], or incisional release of scar contracture; first 100 sq cm or one percent of body area of infants and children) once and +15001 (鈥�each additional 100 sq cm or each additional one percent of body area of infants and children) three times.

To describe the grafting, you鈥檒l report one unit of 15100 (Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or one percent of body area of infants and children [except 15050]) and three units of +15101 (鈥�each additional 100 sq cm, or each additional one percent of body area of infants and children, or part thereof).